Local Monitoring Process Accreditation Endorsement
Local Monitoring
Local monitoring is conducted by the Guilford Center as required by North Carolina Administrative Code 27G.0601 (www.dhhs.state.nc.us/mhddsas/manuals/). Monitoring is conducted for the following providers of publicly funded services:
Category A: includes 24-hour residential facilities, day treatment and outpatient services, except for hospitals (facilities licensed pursuant to General Statue 122C, Article 2).
Category B: General Statute 122C, Article 2, community based providers that do not require State licensure.
Providers are monitored based on the Frequency and Extent of Monitoring (FEM) tool. The implementation of a provider monitoring frequency tool provided by the Secretary determines the frequency and extent of local monitoring based on the LME's level of confidence in each provider. The results of local monitoring reviews may be shared with other LMEs/Area Programs, the Division of Mental Health, Developmental Disabilities and Substance Abuse Services, or the Division of Facility Services. In addition, as always, we maintain a duty to report suspected or alleged abuse, neglect or exploitation to the Division of Social Services. For more information, please visit the DHHS Webite: http://www.dhhs.state.nc.us/mhddsas/
During a local monitoring, providers will be asked to have the
following information available:
• Two or more client files:
- If you administer medications, at least one of the files reviewed
should be of a
consumer that you administer medications to.
- If you use restrictive interventions, at least one of the files
reviewed should be of a
consumer for whom a restrictive intervention has been utilized.
• Two or more personnel files:
- One direct care employee.
- One a clinical supervisor (Qualified Professional).
• Quality Assurance Plan
- Include minutes of meetings for the past year.
• Client Rights Plan
- Include minutes of meetings for the past year.
• Any incident reports for the past year.
• Restrictive intervention logs for the last year, if applicable.
• Evidence of client self-governance.
We will also do a walk-through of your facility, confirm that
nutritious meals are served
(if you serve meals), verify licensure (if facility is licensed),
and assure that records are stored in a manner that protects
confidentiality.
Communicating the results of the local monitoring review
to the provider
All findings will be shared with you before the reviewers
leave your facility. You will have opportunities to ask questions
and/or provide additional information.
A written report of findings will be sent via mail or email within 10 days of the review.
Responding to identified issues
The written summary of findings will contain detailed instructions
on how to respond. Generally, you will be given 30 days to
respond in writing to the findings. When possible, you will
be asked to show evidence of correction. When actual correction
is not possible, you will be asked to submit a plan of correction.
Plans of correction are verified for implementation at your
next local monitoring review.
Accreditation for State Funded Services
When conducted by The Guilford Center, the process involves
the following:
• A review of policies and procedures for compliance with Statutes, Rules
and Codes.
• An on-site review of consumer records and personnel records and a walk-through
of your facility.
If deficiencies are identified, you are given 30 days to respond. Providers are given up to three written reports of findings, with up to three opportunities to respond within defined time frames. If compliance is not achieved or if time frames are not met, the process is terminated. The provider becomes eligible to restart the process one year from the date of notification of termination.
There are also national accrediting bodies. Some examples include the Commission on Accreditation of Rehabilitation Facilities (CARF); Council on Accreditation (COA); and Joint Commission on Accreditation of Healthcare Organizations (JCHAO).The processes involved in national accreditation are not the same as those used in local compliance verification.
Endorsement is a verification and quality assurance process
using statewide criteria and procedures to determine the competency
and quality of Medicaid Enhanced Benefit Providers. Endorsement
will serve as evidence that a provider is complying with Rules
related to the new DHHS service definitions
(www.dhhs.state.nc.us/dma/mp/ServcierDefinitionsRevised022205.pdf).
Providers must be endorsed by a Local Management Entity in order
to enroll with the Division of Medical Assistance as a Medicaid
Provider of Enhanced Services. It does not apply to these service
exclusions: ICF/MR; hospitals (unless providing Assertive Community
Treatment); or independent practice settings or groups.
If services are not currently being provided, a provisional endorsement
will be conducted. This will include review of policy, procedure,
protocol and other documents that will demonstrate compliance
with the service definition. The review will be followed up by
another on-site review for implementation of policy, procedure,
protocol and the other documents reviewed during the provisional
review.
Endorsement Application and Checklist
The provisional endorsement involves a review of “core
rules.”
Core rules include Administrative Publication System Documents
APSM 30-1, APSM 45-1, APSM 95-2, APSM 45-2, and General Statutes
122-C.
• APSMs can be viewed at the Division’s website section on Manuals,
Rules, Publications, Forms and Reports www.dhhs.state.nc.us/mhddsas/manuals/
• General Statute 122C can be viewed at www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/ByChapter/Chapter_122C.html
For additional information about Local Monitoring, Accreditation
or Endorsement:
Contact Alexis Underwood, Mental Health Service Coordinator
Telephone 336.641.4363 or email aunderwood@guilfordcenter.com